Michigan Health Services Initiative
Today the Centers for Medicare & Medicaid Services (CMS) approved a Michigan State Plan Amendment (SPA) for a Title XXI state-designed Health Services Initiative (HSI) for expanded lead abatement activities in the impacted areas of Flint, Michigan and other areas within the state of Michigan. CMS worked closely with Michigan as it developed its plan. The targeted and time-limited HSI will complement other federal, state and local efforts to abate lead hazards from the homes and improve the health of Medicaid and Children’s Health Insurance Program (CHIP) eligible individuals.
Overview
On January 16, 2016, President Obama declared an emergency in Flint, Michigan and ordered federal aid to supplement state and local efforts in response to the lead exposure related to the water system. On March 3, 2016, the CMS approved Michigan’s application to establish a five-year Medicaid demonstration, entitled “Flint Michigan Section 1115 Demonstration” in response to the public health emergency of lead exposure related to the Flint water system. In general, the demonstration expanded coverage for pregnant women and children and created new targeted case management services for beneficiaries exposed to the Flint water supply. The demonstration approval letter stated that we would not authorize lead abatement under 1115 authority but committed that CMS would “design and expeditiously process an alternative option through a targeted and time-limited health services initiative under title XXI of the Social Security Act.”
The SPA will allow Michigan to use a CHIP HSI to abate and ameliorate all lead hazards in the impacted areas of Flint, Michigan and other areas within the state of Michigan. Under this HSI, Michigan will provide coordinated and targeted lead abatement services to protect CHIP children and low income pregnant women at from health risks resulting from lead exposure at eligible homes in the impacted area. This is a time-limited HSI approved for five years from the effective date or until all eligible homes included in the scope of this SPA have been abated for lead.
This HSI will protect from lead health risks populations of Medicaid/CHIP eligible pregnant women and Medicaid/CHIP eligible children (under the age of 19) as follows:
- In Flint, Medicaid and CHIP children and pregnant women up to 400 percent of the federal poverty level (FPL);
- On a statewide basis, Medicaid and CHIP children with a blood lead level greater than or equal to 5 micrograms per deciliter; and
- In other targeted areas of the state, Medicaid and CHIP children and pregnant women up to 212 percent of the federal poverty level (FPL), which is the state’s upper eligibility threshold.
Abatement activities are only permissible for federal funds if the services are delivered to eligible homes where Medicaid or CHIP children or Medicaid or CHIP-eligible pregnant women reside or visit regularly. Eligible homes includes owner-occupied, rental, and those residential structures that an eligible individual inhabits or visits regularly.
Through the HSI, the State will prioritize the impacted area of Flint, Michigan. The State will also identify other high-risk communities within Michigan that will be targeted for HSI-approved abatement activities. These additional areas will be selected based on criteria that identify areas with a high percentage of the population with elevated blood lead levels and old housing stock (which is a good predictor of lead paint in a home). In addition, Medicaid and CHIP beneficiaries that have a blood lead level greater than or equal to 5 micrograms per deciliter in non-target areas will also be eligible for abatement activities. The Centers for Disease Control and Prevention uses 5 micrograms of lead per deciliter to identify children with high blood lead levels.
The state will track and periodically report to CMS approved metrics reflecting the progress of the abatement activities. Some of these metrics include: the number of eligible homes identified with high levels of lead hazards; the number of homes in which lead hazard abatement has occurred; records of actual services provided in each home; and the percentage of children with elevated blood lead levels statewide and in the areas served by this HSI. In addition, the state will track the results of clearance testing to determine if all identified lead hazards have been abated. The state will also maintain a publicly-available registry of all ameliorated homes.
Key Provisions under the HSI
- This HSI will provide coordinated and targeted lead abatement services to eligible homes in the impacted area to ameliorate all lead risks, including:
- The permanent removal, or enclosure, or encapsulation of lead based paint and lead dust hazards from an eligible home;
- The removal and replacement of surfaces or fixtures within the eligible home (this may include water service lines and other fixtures identified during an environmental investigation as lead hazards);
- The removal or covering of soil lead hazards up to the eligible home property line;
- All preparation, lab sampling analysis, clean up, disposal, and pre and post-abatement paint, dust, soil and clearance testing activities associated with such measures including pre and post-water sampling; and
- Training to ensure there is a sufficient number of qualified workforce to complete the lead abatement activities.
- For the purposes of this HSI, abatement services do not include any of the following:
- Work that does not reduce a lead hazard;
- Work not performed by a certified lead abatement professional and/or a licensed plumber;
- Work outside the confines of the property lines of an eligible home, with the exception of the public portion of the lead service lines in Flint and on a case by case basis in other communities following the guidelines put forth in this health services initiative; and
- Work on homes that do not have an eligible Medicaid or CHIP child (under the age of 19 for CHIP) or a Medicaid or CHIP-eligible pregnant women residing or frequently visiting the home
- The state assures that no partial lead service line replacement will be conducted under this HSI. Lead service line replacement must be “complete,” meaning that both the public and private portions of the lead service line will be replaced.
- Services may be rendered to the physical structure and include the surrounding land up to the property line, and would be coordinated with any lead service line removal that occurs outside of the property line.
- Michigan anticipates its total HSI expenditures per year to be approximately $23.8 million, and is planning to spend the full amount remaining under its 10 percent administrative cap to fund the HSI.
- This is a time-limited HSI approved for five years from the effective date or until all homes included in the scope of this SPA have been abated for lead.
HSIs are permitted under section 2105(a)(1)(D)(ii) of the Act and are defined in the regulations at 42 CFR 457.10. Both direct services and public health initiatives are permitted under the statute and regulations. HSI expenditures (including administration of the HSI itself) are subject to a cap that also applies to administrative expenses. Under section 2105(c)(2)(A) of the Act, claims for HSIs and administrative expenses cannot exceed 10 percent of the total amount of title XXI funds claimed by the state each quarter. Within the 10 percent limit, states must fund costs associated with administration, such as outreach, stakeholder engagement, and eligibility determinations of the CHIP state plan, first; any funds left over may be used for an HSI, subject to the 10 percent cap.
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